A clinical study of a new FMT method using hydrogen nanobubble water (NanoGAS® water) without antimicrobial agents has been initiated.

April 20, 2023

Clinical Study on the Efficacy and Safety of a Novel Fecal Microbiota Transplantation Method for Autism Spectrum Disorders

 

Clinical research has been initiated by physicians and others affiliated with our study group.
The study information is publicly available on the jRCT (Japan Registry of Clinical Trials).

https://jrct.niph.go.jp/latest-detail/jRCTs031230041

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Overview (Based on publicly available jRCT data)

1. Purpose and Details of the Clinical Study

Purpose of the study

The purpose of this clinical study is to evaluate the efficacy and safety of a “novel fecal microbiota transplantation (FMT) method using a fecal microbiota solution (SHIN-1) prepared with hydrogen nanobubble water” for Autism Spectrum Disorder (ASD).

This FMT method is being developed as a novel approach that does not require antibiotic pretreatment or bowel lavage prior to FMT—procedures typically required in conventional studies. Furthermore, it can be performed with a significantly smaller bacterial dose (approximately 1/1,000 of the dose used in previous studies).

DIFFERENCE BETWEEN THE NEW FMT METHOD AND THE CONVENTIONAL FMT METHOD (CONCEPTUAL DIAGRAM)

 

Study Phase
1. Early-stage exploratory clinical study

Planned Study Period
April 18, 2023 – March 31, 2025

Target Sample Size
30 subjects

Study design
Multicenter, non-randomized, open-label, single-arm, pre-post comparative study

Target disease
Autism Spectrum Disorder(ASD)

Inclusion Criteria

1. Children aged 5 to 12 diagnosed with ASD by a board-certified pediatric neurologist, neuropsychiatrist, child and adolescent psychiatrist, or pediatric psychiatrist (Medical certificate required; any gender) (Note 1).

　List of pediatric neurologists certified by the Japanese Society of Child Neurology: https://www.childneuro.jp/modules/senmoni/

2. Subjects in generally good physical health aside from gastrointestinal symptoms (at the discretion of the principal investigator (Note 2)).

3. Subjects capable of providing informed assent to participate in this study through written documents, or when necessary, through illustrations or verbal explanations.

4. Subjects whose legally acceptable representative (proxy) can provide written informed consent for their participation in this study.

Exclusion Criteria

1. Subjects currently receiving pharmaceutical treatment.
2. Subjects who have received antibiotics (excluding topical antibiotics) within the past 3 months.
3. Subjects who have undergone a fecal microbiota transplantation within the past 12 months.
4. Subjects with monogenic disorders presenting with ASD-like symptoms (e.g., Fragile X syndrome, Rett syndrome, Joubert syndrome, or other conditions that may affect the efficacy assessment).
5. Subjects with neurosurgical or neurological diseases.
6. Subjects on tube feeding.
7. Subjects who are severely underweight or malnourished (less than 65% of standard body weight).
8. Subjects who have undergone surgery within the past year or are scheduled for surgery within the next 6 months.
9. Subjects currently participating in another clinical trial.
10. Subjects deemed unsuitable for participation by the principal investigator for any other reasons.
    

Treatment Protocol

1. Administration Schedule for the SHIN-1 Enema Solution

The SHIN-1-containing enema solution will be administered rectally once a week for 6 consecutive weeks (6 doses in total). The final efficacy evaluation will be based on the results at Week 30 following the first administration.

2.Weekly Composition of the SHIN-1 Enema Solution

The composition of the enema solution to be administered from Week 1 to Week 6 is as follows: The amount of undiluted SHIN-1 solution for each weekly dose is set at 3g, 5g, 7g, 9g, 11g, and 13g, respectively. Six types of enema solutions will be prepared by adding 100g of physiological saline to each of these SHIN-1 volumes.

Considering that the subjects are young children, a thin rubber enema tube (6.5 mm in diameter) is selected and used for rectal administration.

Discontinuation Criteria

The principal investigator will discontinue the study for a subject if any of the following apply after enrollment:

1. An adverse event occurs, and the principal investigator determines that continuing the study poses an unacceptable risk to the subject’s health.
2. The subject requests to withdraw from the study.
3. Concomitant medications or therapies are used; however, discontinuation is not required if the Efficacy and Safety Evaluation Committee determines that they will not affect the study results.
4. The subject is found to be ineligible.
5. It becomes impossible to conduct the necessary observations or examinations due to the subject’s circumstances.
6. The principal investigator determines that the intervention should be discontinued for any other reason.

The coordinating investigator will discontinue or suspend the study if any of the following occur:

1. New critical information is obtained that may adversely affect subject safety or the study’s conduct, such as when the incidence of anticipated adverse events or malfunctions significantly exceeds initial expectations.
2. It is deemed extremely difficult to achieve the target sample size, such as when subject enrollment is significantly delayed.
3. The Certified Review Board (CRB) recommends the discontinuation of the study.
4. Any other circumstances arise that necessitate the discontinuation or suspension of the study.

Primary Endpoints

1. SRS-2

1)To analyze the changes in ASD severity and the changes in the severity of core symptoms.

(Note: With the “novel FMT method using SHIN-1”, significant alleviation of ASD symptoms was observed in 10 out of 14 cases (71%), including 6 severe cases, at 8 weeks post-transplantation in preliminary cases.)

Secondary Endpoints

1 . Gazefinder (Note 3)
1)To analyze the changes in ASD severity before and after FMT based on the gaze fixation rate on specific areas.

2. PHQ-4
1)Consists of a 4-item scale assessing depression and anxiety.

3. GSRS (Gastrointestinal Symptom Rating Scale)
1)A 15-item questionnaire evaluating gastrointestinal symptoms.

4. BS Score (Bristol Stool Form Scale)
1)An index classifying stool into 7 types based on shape, color, and consistency.

5. Incidence and frequency of adverse events
Adverse events will be evaluated at the time they are observed.

(Note 1) Rationale for setting the age of study subjects (children with ASD) to 5-12 years

There is a global consensus among pediatricians and psychiatrists that interventions for individuals with ASD should begin as early as possible (Zwaigenbaum L et al., Pediatrics 136, 2015, Suppl 1, S10-40, etc.). However, when children are research subjects, sufficient ethical consideration respecting their human rights is essential, necessitating the selection of subjects capable of providing informed assent.

Research on the communication functions (comprehension and expression) of 4- and 5-year-old children with ASD (Bal et al., Autism Res, 2018, etc.) indicates that communication skills improve significantly by age 5, enabling them to “purposefully and voluntarily select objects to direct their attention to.” Based on these findings, 5-year-olds are considered capable of communicating assent, thus 5 years was set as the lower age limit.

As age increases, the characteristics of ASD can cause friction with society, triggering excessive stress and trauma. This can lead to secondary complications such as anxiety and depression, making treatment more difficult. Elementary schools often have special needs classes, creating environments where secondary complications are less likely to occur. For these reasons, the upper age limit was set at 12 years. These criteria were established considering both ethical requirements and the age range with a lower incidence of secondary complications.

Additionally, in previous studies on “FMT treatment for children with ASD” conducted in the U.S. and China, as well as in ongoing (or enrolling) advanced clinical trials, the target age has been lowered to 2 and 3 years, respectively.

Table Age Range of Study Subjects in Prior Studies and Ongoing (or Enrolled) Clinical Trials

Implementing agency	stage	Age Range of Study Subjects
University of Arizona	Prior Clinical Studies	7-17 years old
Third Military Medical University	Prior Clinical Studies	3-17 years old
ProgenaBiome	clinical trial	2 years old or up
Ventura C.Trials	clinical trial	2 years old or up
LA Children’s Hospital	clinical trial	5-17 years old
University of Arizona	clinical trial	5-17 years old
wuhan university	clinical trial	3-18 years old

(Note 2) Selection of Principal Investigators  (6 facilities)

Physicians with experience (at least 3 cases) in performing the “novel FMT using the fecal microbiota solution (SHIN-1)” for children with ASD in private practice (uninsured clinical practice) were selected.

Tanaka Clinic (Osaka)	Dr. Yoshinori Tanaka	https://www.tanaka-cl.com/fmt.html
Shirotani Biowellness Clinic (Kobe)	Dr. Masahiko Shirotani	https://www.lukesashiya.com/feature/flora.html
Kitamura Clinic (Fukuoka)	Dr. Kunihiro Kitamura	http://www.kitamura.or.jp/contents_fmt.html
Kawai Internal Medicine Clinic (Osaka)	Dr. Yuichi Kawai	https://www.kawai-medical.com/diagnosis02/
Natural Art Clinic (Tokyo)	Dr. Yasuhito Mikawa	https://naturalartclinic.com/alternative-therapy/1549
Haruna Clinic (Osaka)	Dr. Reiko Haruna	https://www.haruna-clinic.com/541-2

(Note 3) Gazefinder

This device is a tool to objectively evaluate ASD characteristics based on visual behavior, such as tracking where the subject looks while watching a 2-minute video. Because the test only requires looking at a screen, it places minimal burden on the child. It is drawing attention as the world’s first diagnostic support device for ASD combining both objectivity and quantitativeness.

This technology was developed by Professor Kenji Tsuchiya (Hamamatsu University School of Medicine) and Professor Taiichi Katayama (Osaka University Graduate School of Medicine), who are participating in this clinical study. JVCKENWOOD Corporation is currently applying for regulatory approval in Australia and Japan.

(IMAGE COURTESY OF JVC KENWOOD CORPORATION)

2. Schematic Diagram of the Study

Open-label, pre-post comparative study

Open-label, pre-post comparative study

1. Since this is an early-stage exploratory clinical study involving young children, we opted for a single-arm, pre-post comparative study without a control group to prioritize ethical considerations.
2. The rationale that “efficacy can be demonstrated via a pre-post comparative study” is based on evidence that continued standard rehabilitative care during the study period “will not impact the outcomes of this study.” Specifically, Tachibana et al. at the National Center for Child Health and Development reported in their meta-analysis of randomized controlled trials on ASD rehabilitation programs that interventions did not yield significant differences in outcomes such as ASD severity, developmental index, receptive language, and expressive language.
3. Prior studies investigating the efficacy of FMT for ASD at the University of Arizona (U.S.) and the Third Military Medical University (China) also employed a pre-post comparative design.

3. Exploratory Endpoint: Analysis of the Gut Microbiota Composition in Children with ASD using 16S rRNA Gene Sequencing

The analysis will be conducted at the following time points:

• Before FMT
• Week 8 after FMT
• Week 30 after FMT

Based on previous studies, we have found that the gut microbiota composition of children with ASD exhibits five distinct characteristics differing from those of typically developing children. In this clinical study, we will investigate the diagnostic potential of these five characteristics for ASD.

4 . Use of “SHIN-1 Prepared from Pooled Stool” and Lot Management

Previously, Symbiosis Inc., in collaboration with our medical institutions, managed the raw materials and intermediate lots for treating ASD with FMT. However, in all those cases, different donor stools were used for each study subject (child with ASD).

In this clinical study, SHIN-1 prepared from pooled and stored stool obtained from a single, perfectly healthy donor will be administered to all 30 children with ASD. In other words, every subject will receive SHIN-1 containing the exact same fecal microbiota profile.

Lot management will be conducted as before. Specifically, lot numbers will be assigned to the pooled stool and SHIN-1 from the single healthy donor. These will be linked to the donor’s clinical and laboratory results, stool tests (including infectious disease screening), and 16S rRNA gene sequencing data, as well as to the anonymized pre- and post-transplant examination results of the study subjects. All records will be securely stored for 20 years.

Furthermore, aliquots of the donor’s stool, serum, plasma, whole blood, and urine used for testing will be cryopreserved at -80°C for at least 20 years.

5. Schedule for Observations, Examinations, and Evaluations

The principal investigator will collect data in accordance with the “Observation and Examination Schedule.” As a general rule, the same principal investigator will conduct all examinations, observations, and evaluations for a given subject.he principal investigator will collect data according to the “Observation and Testing Schedule. In principle, the same principal investigator will conduct the examination, observation, and evaluation of the research subjects.

Study Calendar 

Contact: Secretariat of Clinical Research
E-mail: rinshokenkyu.jimukyoku@gmail.com
TEL: 06-6356-2220 FAX: 06-6777-2204 (Weekdays 10:00 – 18:00)